Though we are sympathetic to the concerns raised in their article there are several issues that have not been adequately addressed. The first is to be sensitive to an important distinction, namely, that between low-income and middle-income countries as defined by the Human Development Index. Low-income countries’ academic institutions have, as Chattopadhyay and colleagues point out, free access to all major bioethics journals via HINARI. There might be bureaucratic hoops and loops libraries jump through, but it can be done, provided there is sufficient interest in those countries in achieving access.

The authors point out some of the other obstacles faced by scholars in these countries, such as unreliable access to electricity or the Internet. One could add violence and gender inequality in many of these countries as serious challenges to many researchers or potential scholars. Obviously, the fundamental lack of infrastructure to support researchers in these countries is lamentable. Presumably the authors recognize that these issues are far outside the scope of the role or ability of academic journals (much as we wish we had the power to intervene on these issues).

Then there are countries such as India, Brazil, Mexico, and China that do not enjoy free access to academic journal content via HINARI. This is potentially an obstacle to access for scholars in these countries. These are countries that are not devastatingly impoverished. Parts of China have a higher gross domestic product (GDP) than certain parts of the United States. India is busy financing its space research to the tune of US$1.5 billion per year. These countries are sufficiently wealthy that they could decide that ensuring access to academic literature for its academics is important enough to pay for it. Apparently, these countries have other political priorities.

In a previous publication, the same authors made the relevant distinction and placed these “high-income” countries in the same category with “very-high-income” countries such as Germany. It is important for researchers to be consistent in their methodology if data are to be used to support normative claims.

While there is no doubt that some individuals in these countries may lack easy access to relevant literature (which may also be true for some non-academically affiliated, resource-poor individuals within the United States or Europe), other existing options for these individuals include contacting those authors via e-mail to ask for an electronic reprint. But it is possible (and likely) that the current system of charging subscriptions through institutions and using HINARI, plus individual requests for reprints, will still leave some individuals at a systemic disadvantage. What are the alternatives?

Recognizing that producing and publishing articles costs money, the authors and some commentators seem to support Open Access initiatives as a “conscientious response to the crisis.”

Is Open Access a more just business model? While access to those publications’ content is free, publishing in them is not. The problem remaining, then, is how to ensure adequate representation of content produced by authors hailing from the global south. In other words, the financing problem has been shifted from subscribing libraries to paying authors. While this would help resolve the access issue for academics in the global south, it would not resolve the issue of how they would get their research published. Waiver of fee programs analogous to HINARI might be implemented for scholars from very-low-income countries. But again, it is likely that the same scholars who struggle to get access in the current system from higher income countries like China, India, and Brazil will struggle to be published, even under partial waiver of fee programs that differentiate between different types of countries. Given existing fee structures for most open-access journals, it is likely that a lot more scholars (including those in the global north) will struggle to be able to publish their research.

It is also worth noting that journals increasingly allow a mixed approach. For example, any authors can have their content in our journals (AJOB, Bioethics, and Developing World Bioethics) made open access by paying the requisite fees under policies like those of most open-access journals. It speaks to the challenges of open access that few authors choose this option. Of note, there is one journal, the excellent Indian Journal of Medical Ethics, which both is Open Access and does not charge article processing fees. However, as the authors point out, this depends on the “cost of countless hours of unpaid work and sacrifice on the part of its staff and editors.” Self-exploitation is not a sustainable or just solution to the challenge of funding the production of academic content.

We agree with the authors that there is a lack of peer-reviewed outputs in bioethics from low- and medium-income countries (LMICs). What is far from clear is why there is that lack of outputs. It is implied that lack of access to journals has much to do with it. But there are other, likely more powerful causes and explanations. For example, there is a lack of bioethics capacity (e.g., graduate programs) in many of those countries. China has only recently significantly boosted government funding made available for the establishment of bioethics teaching programs in its medical schools. Perhaps unsurprisingly, bioethics journals these days see a significant increase in submissions from that country, and indeed, a significant uptick in terms of their readership hailing from that country. Bioethics journals are also digitally available via Chinese library consortia these days. Some of China’s leading voices have been appointed to relevant academic journals’ editorial boards, as they should be. Another possible explanation is that authors in particular countries of the global south might choose to publish their content in national or regional publications, for no reason other than that they expect to have a greater impact and interested audience in that type of publication.

We are sympathetic to the authors’ worry that issues of concern to LMICs, approaches to bioethics topics from the perspective of non-Western cultures, and scholarship from researchers in those countries have been underdeveloped in bioethics. This is not surprising, since bioethics is an academic field that originated in the global north and has a several-decades-old history there. But we are much more optimistic than the authors and see that significant progress is being made. One of us (U.S.) co-founded many years ago a specialized journal (Developing World Bioethics) to help address the gap. An upcoming issue on “African bioethics,” with the guest editor and all authors, bar one, actually living and working in African countries is something that would likely not have happened in a mainstream bioethics journal 10 years ago. We have today journals such as the Indian Journal of Medical Ethics, Journal of Global Ethics, Public Health Ethics, and any number of other journals that publish frequently both on issues of concern to the global south, as well as from authors hailing from there. Asia Bioethics Review with its obvious focus on Asian approaches to bioethics is another welcome addition that can broaden the range of scholarship in the field. In addition to this, there are many bioethics journals published in non-English-language formats in countries such as China and Turkey, to name just two.

Despite the progress being made, researchers in many LMICs face challenges with producing and publishing scholarship in bioethics. Some of the articles in this issue suggest that open access is a potential panacea for the problem. For journals in the humanities (including bioethics), we should allow multiple approaches to flourish. We do not believe that open access represents a sustainable and just solution to the problem, any more than subscription-based financing models do. The reality of the financial requirements for publishing journals means trade-offs and engaging in efforts (like HINARI) to try to do the best we can to mitigate inequalities as they arise.